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Professor and physician executive David Edward Marcinko MBBS DPM MBA MEd BSc CMP® is originally from Loyola University MD, Temple University in Philadelphia and the Milton S. Hershey Medical Center in PA; Oglethorpe University, and Atlanta Hospital & Medical Center in GA; and the Aachen City University Hospital, Koln-Germany. He is one of the most innovative global thought leaders in health care business and entrepreneurship today.

Dr. Marcinko is a multi-degreed educator, board certified physician, surgical fellow, hospital medical staff President, Chief Education Officer and philanthropist with more than 400 published papers; 5,150 op-ed pieces and over 125+ international presentations to his credit; including the top 10 biggest pharmaceutical companies and financial services firms in the nation. He is also a best-selling Amazon author with 30 published text books in four languages [National Institute of Health, Library of Congress and Library of Medicine].

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Dr. Marcinko Interviewed on the Physician Credit Crunch

Financial Experts Share Tips on Obtaining Loans to Start or Expand a Medical Practice

By Michael Gibbons

Editor: ADVANCE Newsmagazines

Maybe you’re a young dermatologist or plastic surgeon who dreams of starting your own practice. Or maybe you’re an established professional but want to expand your palette of anti-aging services. Either way, you’ve probably made an unpleasant discovery: Banks are leery about lending today. Global recessions with seemingly no end in sight tend to give loan officers sticky fingers.HO-JFMS-CD-ROM

Dermatologists and Plastic Surgeons

We have it on good authority that dermatologists and plastic surgeons as a group are less affected by this problem than physicians in some other branches of medicine. Still, there’s no better time than now to absorb some sound advice on how to approach banks for loans—whether you’re a fresh-faced newcomer to the fresh-face business or a wrinkled veteran at eliminating wrinkles.

Start Small

There’s no soft-soaping it: Starting a healthy aging practice is much harder than expanding an existing practice, even in the flushest of times.

“For young dermatologists starting out, I recommend you start small,” advises Jerome Potozkin, MD, who offers facial rejuvenation, liposuction, body contouring and dermatological care through his practice in Walnut Creek, CA. “You can always expand. Keep your overhead low. Know what your credit score is and do everything you can to improve it. Pay your bills on time.”

Lasers aren’t cheap. Besides the initial acquisition costs, a service contract can cost $7,000 to $12,000 a year, according to Dr. Potozkin. “Don’t feel you have to buy every new laser under the sun,” he says. “In fact, renting rather than purchasing is an option many companies offer. When your volume is low you can rent and schedule laser days—although the pitfall there is you don’t have lasers available whenever patients come in.”

Also, young dermatologists “will probably have an easier time getting a loan if they go to a relatively underserved area, as opposed to an area that has a large number of dermatologists per capita,” says Dr. Potozkin, who began practicing 10 years ago. “There are two schools of thought on this: Go where you want to live to start a practice or go to where there’s a need and be instantly successful. I chose the former. It took me longer to get started but I’m very happy where I am.”

Patience, Prudence and Passiondem2

Be patient, prudent, passionate—and start with a spare office and as little debt as possible, advises Dr. David E. Marcinko MBA, a financial advisor and Certified Medical Planner™. Marcinko, a health economist,  is CEO of the Institute of Medical Business Advisors Inc., a national physician and medical practice consulting firm based in Norcross, GA www.MedicalBusinessAdvisors.com

“Patients are looking for passion from you, not lavish trappings,” Dr. Marcinko says. “When a banker or a loan officer sees $175,000 or more of debt they are loath to give a loan—and it’s hard to blame them. Purchase a home after you become a private practitioner. You need to be as close to debt-free as you can be.

Exit Strategy

“Another thing bankers want to know is, ‘If we give you a loan and you start a practice and it fails, how will we be paid back?’ They want an exit strategy.”

The good news is dermatology “remains a very lucrative specialty, and in most parts of the country they are in a shortage position, particularly with the aging population,” says Sandra McGraw, JD, MBA, principal and CEO of the Health Care Group, a financial and legal consulting firm based in Plymouth Meeting, PA., that advises the American Academy of Dermatology, among other groups.

“I would start with a realistic business plan for why you think this practice can succeed, in the specific location,” McGraw says. “How many patients do you expect to see? How will they know you are there and available? Remember that banks lend to all kinds of people, so keep your numbers realistic. Overestimating expenses is as bad as underestimating them. Then determine how you want the money—usually a fixed loan for a period of time and then a line of credit as you get your practice going and sometimes need the cash flow.”biz-book

Expanding a Practice

Established dermatologists should have an easier time getting loans to expand their practices. They have, one hopes, a track record of success and assets to put up as collateral.

Mid-career physicians “have cash flow, physician assets and equity to some degree in a house and personal assets,” Dr. Marcinko observes. “Banks can attach loans to personal assets and savings accounts. Ninety-nine percent of times you must sign a personal asset guarantee. Mid-lifers have assets young ones don’t, so mid-lifers aren’t quite the risk. They have businesses that have value and cash flow. Banks like cash flow.”

However, even veterans must do some homework before approaching a bank. “You still want to establish why you want the money and how the expansion will increase your income,” McGraw says.

Another tip: If the bank has loans out with reputable vendors, you might ask the loan officer to recommend them to you as potential contractors. “Sometimes keeping it local and supporting others with loans at the bank can be helpful,” she says.

Assessment

Dr. Marcinko adds, “Bankers today want you to come in with a well-reasoned, well-thought-out and well-written business plan. Give bankers a 30-second elevator speech on why you are different. It’s really important to ask yourself, ‘What can I offer the community as a doctor in my specialty that nobody else can?’ If you bill yourself as the first dermatologist to do laser surgery, that’s a perceived advantage. You purchased the equipment and learned to use it. But anyone can do that. If you can come up with something that nobody else has or can do, that’s how you’re successful in anything.”

Link: Dr. Marcinko Interview

Link: https://healthcarefinancials.files.wordpress.com/2009/08/dr-marcinko-interview.pdf

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More on Medical Practice Business Costs

Unknown and Under-Appreciated by Many

By Rick Kahler CFP®

I recently talked with an administrator of a private medical practice about some of the financial challenges she faces in dealing with the medical system, insurers, and patients.

Some of the insights she gave me into the realities that private physicians face in providing medical care were rather disturbing.

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Here are a few of them.

Let’s start with the insurers who account for the bulk of their revenue. Many payments for procedures from insurance companies (including Medicare) are below the cost of providing the service. This forces physicians to make up the difference on other procedures or find other sources of income to sustain the profitability of the practice.

Conversely, in markets that have just one hospital, the insurance companies have no leverage. If the insurers won’t pay what the hospitals demand, the hospitals can threaten to drop out of the network, leaving the insurers with nowhere to send their insureds in those markets. The insurers end up agreeing to pay the hospitals more.

Charges for services provided in-house at the hospital can end up being substantially higher than those same services done by outside providers.

Example:

She gave me an example of a lab test that cost $1,500 to $2,000 at the hospital lab but $35 to $80 at an independent lab. Patients do have the option to direct the hospital to use an independent lab. But, how many people know that and will have the presence of mind to make the request? While it makes financial sense to price-shop if you have a high deductible HSA plan, there isn’t much incentive if your plan has low deductibles.

Collections

Another challenge is collecting from patients. She says a surprising percentage of Americans maintain checking accounts with no money or keep checks from accounts which have long been closed. While writing bad checks is a crime, those who game the system know they can probably get by with writing a low-dollar check because the cost of pursuing justice is much more than the check is worth.

Most companies would never do business with such a person again. Healthcare professionals tend to have a bias toward giving everyone services, so these same people do return requesting care. She said she and her physician employer have had huge internal arguments about this. Her position is that these people take advantage of the physician in a premeditated fashion and don’t deserve to be extended services. The physician argues that everyone, even deadbeats, deserves healthcare. Since the practice doesn’t provide life-and-death services, she was able to get the physician to agree that if someone has an outstanding bill they need to settle it upfront, in cash, before any new services are provided.

Then there are those who use credit cards and then fraudulently dispute the charges. Some providers let this go because of the difficulty of proving that the charge is legitimate. It requires photographs of customers during the transaction, copies of driver’s licenses, customers’ signatures on the paperwork, and notarized statements from the provider verifying that this was the person who received services and presented the credit card.

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SSNs

A final interesting point concerned patients’ Social Security numbers. She said the only time these are ever needed is when an outstanding bill is sent for collection. Otherwise, they are never accessed or used.

Assessment

Finally, she was quick to add that only a small fraction of their patients premeditate stealing from them. She also stressed that not all insurance companies or hospitals behave unethically, and some do wonderful, humane acts of kindness. Nevertheless, the lack of integrity that does occur on both sides is infuriating and adds to the cost of health services.

Conclusion

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Cancer Projections for 2017

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1,190 Children Are Projected to Die From Cancer in 2017

The American Cancer Society recently released projections for cancer rates in American children for January 2017. Here are some key findings from the report:

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Cancer is the 2nd leading cause of death in children ages 1-14, after accidents.
In 2017, an estimated 10,270 children 1-14 will be diagnosed with cancer.
1,190 children are projected to die from cancer in 2017.
Leukemia accounts for almost a third (29%) of all childhood cancers.
26% of childhood cancers are brain and other nervous system tumors.
Cancer incidence rates increased in children by 0.6% per year from 1975-2013

Source: American Cancer Society, January 5, 2017

Conclusion

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A Free Market Repudiation of Evidence-Based Medicine

Michel AccadIn a recent article entitled “A Hayekian Defense of Evidence-Based Medicine” Andrew Foy makes a thoughtful attempt to rebut my article on “The Devolution of Evidence-Based Medicine.”  I am grateful for his interest in my work and for the the kind compliment that he extended in his article.  Having also become familiar with his fine writing, I return it with all sincerity.  I am also grateful to the THCB staff for allowing me to respond to Andrew’s article.

Andrew views EBM as a positive development away from the era of anecdotal, and often misleading medical practices:  “Arguing for a return to small data and physician judgment based on personal experience is, in my opinion, the worst thing we could be promoting.”  Andrew’s main concern is that my views may amount to “throwing the baby with the bath water.”

On those counts, I must plead guilty as charged.  I have been trying to sink that baby for a number of years now, attacking it from a variety of angles.  I have made a special plea in favor of small data and I have even questioned the intellectual sanity of EBM.  On the question of the coexistence between EBM and clinical judgment, I have been decidedly intolerant, relegating EBM to second class citizen status.  In other words, I’m an unapologetic EBM-denialist which, as I found out yesterday on Twitter, puts me in the same category as climate change skeptics.

My main concern today, however, is to address the relationship between EBM and the free-market, and to reject Andrew’s point that EBM is somehow compatible with it.  First, though, let me say that in no way do I deny the notion that American medicine has, for decades, harbored practices of highly doubtful benefit to benefit to patients, and that many such practices may, in fact, have been dangerous or harmful.  I am fully on board with any effort to eradicate “eminence-based medicine.”

But before we reach out for an EBM solution to that problem, perhaps we should first wonder about causes.  What keeps the errors of eminence-based medicine persisting for so long?  Why do patients and doctors remain so wedded to a course of therapy as to blithely engage in unbeneficial or even harmful care?

If I read Andrew correctly, he seems to believe that these errors persist because outcome uncertainties are inherent to clinical care, hence the need for EBM. But that cannot be the fundamental reason.  Why would patients continue to pursue a treatment for which they have neither objective nor subjective tangible benefit?  Why wouldn’t they refuse to go along?  After all, many of them do exercise their ability to be non-compliant in the case of treatments deemed beneficial to them according to the truths of EBM!

Outcome uncertainty, then cannot be the reason why futile or harmful treatments persist, and if outcome uncertainty is not the reason, reducing it by way of EBM may not be the answer either.

What eludes Andrews is that eminence-based medicine is not simply the result of individual doctors exercising judgment with limited knowledge. Rather, eminence-based medicine happens when doctors apply their own pet theories and disregard the needs and wants of the patient at hand.

By missing that point, Andrew misses that eminence-based medicine is precisely minimized by the free-market and, on the contrary, encouraged by government intervention.  The history of American medicine provides ample examples to make that point.

In the late nineteenth century, healthcare in the United States was uniquely unregulated.  Yet, contrary to common belief or fabricated myths, care was improving by leaps and bounds, getting at once better, cheaper—and more scientific.  It is during that time that some of the finest medical institutions emerged, including the Mayo Clinic and the Johns Hopkins Hospital.  Sure, there were snake oil salesmen, but these were by-and-large being driven out of business by a growing community of serious, well-trained, and effective physicians.  And competition among these practitioners kept them humble and at the service of patients.

All of this changed in the 1910’s when, following the Flexner reforms, state licensing laws were enacted.  It is in the heels of these laws that medical paternalism emerged.

As an illustration, consider this passage excerpted from an official report published soon after the enactment of licensing laws:

The physician is the outstanding practitioner of medicine.  The need and the value of his service sets him above all others.  He alone, of all types of medical practitioners in the United States, is permitted by law to diagnose and treat all diseases and conditions and to use (with certain minor exceptions) any form of diagnostic or therapeutic technique which he considers necessary, desirable, and within his professional skill.  (Report of the Committee on the Cost of Medical Care, 1928, p. 195)

From that point onward, medical abuses of privilege became much more widespread than they had been.

Furthermore, as Kenneth Ludmerer has pointed out, this elevation of the physician to the status of demi-God by government fiat went hand-in-hand with the rise of the academic ivory tower, since academic medical schools were producing the “cream of the crop” among doctors.  Academic ivory towers, naturally, become common sources of practices founded on eminence.

Of course, licensing laws and the emergence of the ivory towers are not the only factors to consider.  Other government interventions soon followed to bring about systems of third-party payment for medical care—health insurance.  Without these government interventions, and without the existence of licensing laws, it is unlikely that health insurance would have emerged from the free market.  By unmooring medical decisions from any financial constraints, health insurance contributes immensely to the perpetuation of eminence-based practice.

It is this regulatory context, then, that is at the root of eminence-based medicine, and not the uncertainties of clinical care which, in a profound way, are inherent to the medical encounter.

Andrew believes that EBM discovery is akin to price setting on the free market.  I strongly disagree with that analogy.  As Andrew himself has noted, prices set in the free market convey consumer values and are the end results of myriad decisions made on the basis of dispersed knowledge.

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The-Psychology-of-Analytics-When-Working-is-Not-Working

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EBM results, on the other hand, are statistical relationships between interventions and outcomes which are carefully selected by investigators in highly contrived experimental settings.  In these settings, the choices and preferences of doctors and patients are ignored or neutered by design in order to isolate the relationship of interest.  Any value obtained as a result of an EBM experiment is primarily imputable to the investigators or sponsors, and only secondarily (and statistically) of benefit to patients.

EBM is no free market phenomenon.  EBM is an academic invention incubated in Canada, a country with a single-payer healthcare system!  As I described in my article, this invention has spun out of control and has turned EBM into a weapon wielded with equal vigor by the pharmaceutical industry, by regulators, and by those who aim to equalize the historical excesses of eminence-based medicine through the dubious doctrine of “Less-Is-More.”  None of these movements, it seems, are motivated by a desire to advance a genuine human science that is meaningful to individual patients.  In fact, to the extent that is a pet theory which standardizes care for entire populations, EBM is eminence-based medicine on steroids.

But if EBM is by no means a product of the free market, can the free market address our need to improve therapeutic predictions or will it set us back to a clinical stone age?

So long as narrowing clinical outcome expectations is truly desired by doctors and patients—and there is no reason to doubt that it is—then the free market is demonstrably the optimal environment that can allow human ingenuity to devise clever ways and methods to achieve that goal.  But what shape or form would those methods take and how closely would they resemble what we now take to be evidence-based science, I have no idea.  If I believed I held that knowledge, I would be repudiating Hayek.

Assessment

EBM Systems Engineering Vision MARCINKO

An FA Hayekian Defense of Evidence Based Medicine

About

Michel Accad is a cardiologist who practices in San Francisco.  He blogs at Alert and Oriented and can be followed on Twitter @michelaccad

Conclusion

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[Executive-Director]

If you are not reading our subscriber “comments”, you are not getting all you can from each Medical Executive-Post. And, if you are not reading the links in each post, you are not getting all you can from the ME-P.

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Great Book Gifts for Medical School and Health Care Graduates

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[By Staff reporters]

An Educational Resource Supporting Doctors, Universities and Consulting Advisors  

We are an emerging online and onground community that connects medical professionals with financial advisors and management consultants. We participate in a variety of insightful educational seminars, teaching conferences and national workshops. We produce journals, textbooks and handbooks, white-papers, CDs and award-winning dictionaries. And, our didactic heritage includes innovative R&D, litigation support, opinions for engaged private clients and media sourcing in the sectors we passionately serve.

Through the balanced collaboration of this rich-media sharing and ranking forum, we have become a leading network at the intersection of healthcare administration, practice management, medical economics, business strategy and financial planning for doctors and their consulting advisors. Even if not seeking our products or services, we hope this knowledge silo is useful to you.

In the Health 2.0 era of political reform, our goal is to: “bridge the gap between practice mission and financial solidarity for all medical professionals.”

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Introducing Physician-Focused Consumerism [PFC]

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A New Process or Just a New Term?

[By Staff Reporters]

According to Javier Sanabria, Physician-Focused Consumerism is a set of initiatives designed to align physician decision making with high-quality healthcare outcomes provided in a cost-efficient manner.

 manage

Physician-focused consumerism can include the redesign of financial incentives, greater access to patient data, decision support tools, ongoing education about treatment alternatives, and an understanding of the financial impact of alternatives on patients. It can be the basis for collaborative efforts between employer health plan sponsors, provider systems, and physicians to help achieve high-quality care in a cost-effective manner.

Assessment

See more at: http://www.healthcaretownhall.com/?p=7450#sthash.AgjagVO7.dpuf

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On Next-Generation Medical Practice Management Strategies

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Establishing the Way-Forward

[By Dr. David Edward Marcinko MBA CMP™]

dr-david-marcinkoMedical practices today are operating in a new or next-generation practice management environment. There are significant pressures on physicians to increase, or at least maintain revenues and bottom line profits. These pressures are coming from many sources.

First, there is the increase in managed care penetration. As managed care grows, and the ACA implements via ACOs, doctors are forced to sign up with these health plans in order to maintain their patient base. They perform the same services but get paid less for them. Reimbursement is undergoing a paradigm shift, progressing from retail, to a wholesale, mentality. Capitation is changing reimbursement patterns. When capitation becomes the payment system, most doctors lose revenue simply because they do not know how to practice in this type of payment environment.

Second, payers’ have a continuous desire to reduce costs, including federal government programs such as Medicare and Medicaid. Many are bundling services together into single payments. More importantly, many payers are simply reducing what they pay doctors. Government intervention, such as HIPAA and eHRs, is also putting pressures on practice revenues. Increased scrutiny by the Government with regard to fraud and abuse issues, along with the Stark rules and regulations, have both impacted practice revenues. Some practices have found they cannot create the revenues they used to since Stark became law. As a result of government scrutiny, physicians coding practices have become much more conservative, thus impairing revenue.

Finally, these pressures have created a significant increase in competition within the healthcare marketplace. To increase revenues, physicians are becoming more aggressive in the marketplace. Many are spending more money on marketing activities in order to increase patient volume. Others are forming affiliations or alliances to go out and obtain exclusive contracting relationships, which is another way to increase patient volume.

In aggregate, physicians are now forced to take initiatives to increase practice revenues. Practices that do not place emphasis on this strategic strategy find themselves with declining revenues as well as declining profits. This means less money available for physician compensation. However, some practices have been successful in growing their revenues with the following practical strategies, which vary for each practice and each practice locale.

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Competing for Managed Care Related Contracts

The objective here is to go out and obtain exclusive contracting arrangements that will add profitability, not necessarily volume, to the practice. This usually means entering into an arrangement with a third party payer. To do this, the practice must do two things. First, it must make sure it is positioned so that a payer will want to award a contract to the practice. In other words, it must have something to sell to the payer. For example, primary care practices are attractive to those payers who want to award global risk contracting arrangements. Second, the practice must market itself to these payers. This means going out and meeting with payer representatives about potential contracting arrangements. The meeting should solicit from the payer what kind of exclusive contracting relationships it is looking for and more importantly, what it thinks about the practice itself. In other words, find out if the payer would even consider awarding a contract to the practice.

Ancillary services

A practice should analyze the services that it is now referring out, so that it can bring them in house to generate revenue. This conflicts with hospital-owned practices since the employed physicians refer most ancillaries to the hospital. In other words, because of government rules, the physicians cannot look to these revenues for additional compensation. However, still look for these opportunities – there might be ancillary services the hospital does not render or does not want to render that could be provided by the practice itself.

Examples of ancillary services that most medical practices could implement include lab, radiology (ie, X-Ray, mammography, echo testing, bone density testing, etc.).

Physician Extenders

As a result of declining reimbursement, physicians are spending less time on patient treatments that do not pay well. In other words, they are not spending time on care that could be rendered by someone else (i.e. by a lower cost provider). Adding a physician extender to a practice can increase revenues simply by freeing up physician time to do other, better paying clinical activities.

For example, an extender could conduct certain post-operative visits, which usually are not paid if treatment is within a designated global surgical period. Extenders could also be used to add patient volume, especially in primary care practices. Many busy practices hire extenders in order to allow patients quick, convenient access to a healthcare provider for simple medical conditions. This way, patients do not have to wait for an appointment. As a result, this leverages the volume of patients a practice can treat on a daily basis.

Added Venue Value

In some service areas, a medical practice can branch out to increase revenue. Practices may be successful adding satellite locations in areas that are either underserved or need a more qualified physician. For example, some practices in urban areas have set up satellite offices in other parts of their county, which are usually geographically outside the urban area itself. Since a significant amount of capital will normally be required to start up the office from scratch, it may be more practical to acquire or merge with an existing practice. The emphasis would then be on increasing the efficiency and profitability of that practice site.

Improving Operations and Productivity

In most cases, revenues can be increased for a medical practice simply by improving operations and physician productivity. For example, many practices have problems with their billing and collection activities, including receivables management. Charges do not get billed on a timely basis, collections at the time of service are inadequate, there is a failure to detect incorrect payer reimbursement, and receivable follow up is unstructured or non-existent. All of this can lead to high receivables and low collections – in other words, lower revenues. The entire billing and collection process should be analyzed and evaluated to see if there are any improvements that can be made that could increase practice revenues.

Next, physicians should look closely at CPT® coding patterns. This is critical for those practices operating in a fixed fee environment because fee schedules cannot be increased to generate additional revenues. First, look at your coding for evaluation and management services. Many doctors under code these services and many do not know how to bill for consultative visits. Look at all other coding issues related to your specific medical specialty. Are modifiers being applied correctly? Are surgical complications identified and billed correctly? Are all available CPT® codes being billed? These are just a few examples.

Make sure the practice fee schedule is maximized. There should not be any billing of a service where the billed charge is approved 100% for payment by the payer. This is especially true for managed care payers. To identify these situations, you must have a system in place to review the Explanation of Benefits (EOBs) that are received from the payers with each reimbursement. Look for those charges that were approved 100% for payment. When identified, the related service fee on the practice charge master should be increased immediately.

Finally, for hospital-owned medical practices, increasing physician productivity can result in an immediate increase in revenues. History has shown that physician productivity often declines after a physician practice is acquired. This is usually because the incentives in the employment contract are misplaced. In these situations, the incentive should be placed on the doctor’s base salary and not any bonus possibilities. A doctor will often maintain productivity if he or she knows that his or her base salary could decline if productivity targets are not met.

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Business Med Practice

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The Template Textbook for Success

For comprehensive practice management information on how to increase office efficiency, operations, revenue and profit, an excellent textbook is: The Business of Medical Practice, 3rd edition.

Assessment

Regardless, the keystone of integrated financial planning for all physicians is consistent income. The following practice benchmarking methodology will assist in proactively monitoring this all-important parameter of your financial life, before it is too late.

Conclusion

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TAKE THE POLL

www.MCOL.com and Accountable Care News are conducting the 2013 Accountable Care e-Poll. Please respond by 5 PM Pacific, Friday December 13th, 2013. Results will be emailed to participating respondents upon request.

e-Poll

You can take the e-poll by going to: http://aco2013.questionpro.com/
The e-poll asks the following questions:

  1.  Please indicate your perspective:
  2. Is your organization involved with ACOs- including development, operation, or contracting arrangements?
  3. When would you estimate ACOs would have a material impact in your marketplace:
  4. If ACO Medicare pilots are not ultimately successful, will that cause commercial and Medicaid ACO arrangements to generally fail as well?
  5. What will be the impact of the newly enrolled individuals coming into the system as a result of Medicaid expansion and the health insurance exchanges?
  6. How confident are you that ACOs will actually generate the necessary savings?
  7. Will bundled payments prove to be a more effective delivery and payment reform model than ACOs?

Advocacy

Assessment

Again, to take the e-poll now, go to: http://aco2013.questionpro.com/

Conclusion

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“Learning” about The Business of Medical Practice in Modernity

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The Integrated Patient-Centered Medical Home Model

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Tools for Transforming Our Healthcare

By Matias A. Klein

[VP, General Manager, Clinical Quality and Collaboration, Portico Systems]

The patient-centered medical home (PCMH) continues to attract increasing attention from many industry stakeholders. The PCMH model has the potential to enhance the US healthcare system by rejuvenating primary care in a way that improves clinical outcomes, lowers costs, promotes wellness, and increases patient and physician satisfaction.

PCMH Pilot Programs

PCMH pilots are currently being tested in almost all states, including a 3-year Medicare medical home demonstration project overseen by the Centers for Medicare & Medicaid Services. However, few organizations have scaled the PCMH across their entire healthcare network, and the existing implementations appear to remain focused on care management at the expense of patient wellness. The value of focusing equally on promoting wellness (although an underappreciated nuance in the implementation of a PCMH) is a critical factor in effectively leveraging the PCMH model to improve clinical outcomes and the US healthcare system.

Centered on the Patient

The PCMH model, as its name suggests, is centered on the patient. The underlying thought is that if a comprehensive, longitudinal view of a patient is taken throughout a patient’s lifespan, the patient’s health could be better “managed” and better aligned with best medical practices. It is well documented that physicians do not consistently or frequently apply evidence based, recommended care to patients. Therefore, a major goal of the PCMH model is to improve the consistent application of evidence-based guidelines and best practices, by making longitudinal information about the patient available to providers and to patients – including any risks and recommended “intervention opportunities.” And although adherence to best practices in disease management is crucial, the PCMH model also focuses on preventing costly episodes by promoting and incentivizing wellness.

PCPs = Medical Homes

To effectively manage a patient’s health and promote wellness, primary care physicians – designated as medical homes – need to act as health “quarterbacks” or “coaches.” In such a role, these physicians will assist in aggregating a patient’s health information, making best practices transparent, offering health education and counseling, as well as coordinating the provisioning of any healthcare services the patient may need. With physicians spending significant time coaching and making critical clinical decisions, these services will be delivered with the support of care management nurses, who will handle the majority of the information processing and operational activity.

An Innovation in Care

The PCMH model is an important innovation in care delivery and has the potential to reduce medical and administrative costs, while improving the quality of care. However, how to implement the PCMH model within a care-delivery system remains unclear. Providers need the requisite infrastructure and capabilities at their locations to meaningfully participate in a PCMH. Patients must be engaged over long periods of time in proactively managing and improving their health. Outcomes and quality must be objectively measured to optimize the delivery of best possible patient care.

Potential Value

To realize the potential value of the PCMH, three distinct stakeholders – patients, providers, and health plans – must work in a collaborative way. Getting these stakeholders synchronized (i.e., aligned in their goals, using interoperable tools, and collaborating on an operational level) is no small feat but can be accomplished with the smart application of technology. Bringing these three stakeholder groups together on a common, collaborative technology platform results in what some are beginning to call the integrated PCMH. The integrated approach to the PCMH can best ensure that implementing a PCMH model does not create additional administrative burdens to health plans or provider organizations.

An integrated PCMH provides a framework for stakeholders to collaborate in a transparent fashion, and where quality, best practices, and outcomes are incentivized. The integrated PCMH also provides a pathway being awarded a medical home designation.

Vertical Integration Deployment

The key to deploying an integrated PCMH is an end-to-end vertical integration of the care-delivery process – that is, a process in which the provider network management, automation, information exchange, and analytics solutions are tightly integrated with patient and provider information. With so much complexity and so many “moving parts” in the delivery of the PCMH model, this end-to-end vertical integration is a practical solution that enables effective coordination of care and accurate measurement of quality: with such system integration, the provider network (e.g., the health plan) can bring economies of scale to even the smallest provider offices to optimize the quality of care delivery.

The 5 Keys

The five key components for such an integrated PCMH are:

  1. A source-of-truth for mapping medical home – designated providers, patients, as well as  the associated relationships with health plans and other medical professionals; a central medical home fact checking is critical for effectively identifying, managing, and communicating with medical home and their networks.
  2. A set of collaborative workflows that align stakeholders with best practices, incentives, and quality measures reporting; these collaborative workflows help each stakeholder understand where a given patient is in the care-delivery process, potential intervention opportunities, why certain interventions are being emphasized, and what incentives are available for executing specific interventions.
  3. An infrastructure for clinical integration and distribution of intervention opportunities, clinical reference content, education, alerts, and reminders. This infrastructure allows all stakeholders to have access to up-to-date, accurate patient information; it aligns stakeholders and helps reduce or eliminate duplication of procedures and tests.
  4. Interoperable clinical applications and collaboration tools to enable patients and physicians to engage in medical home processes; these tools – which include electronic medical records, e-prescribing, e-labs, secure e-mail, personal health records, and document management and exchange technology – can help manage health information, assist with decision-making, and improve communication between patients, providers, and health plans.
  5. Incentive management and analytics tools for modeling, setting, measuring, and rewarding incentives based on quality measures and outcomes; these tools must span the entire PCMH delivery process and are required for objectively evaluating and optimizing the performance of a medical home.

When considering the multiplicity of stakeholders, information, software systems, and knowledge that has to be coordinated in the context of a PCMH model, implementing a medical home pilot and scaling it to a full-blown network may seem a daunting task. The integrated PCMH offers a real-world solution for deploying a scalable and flexible infrastructure for the management of this emerging care-delivery model.

Assessment

Early evaluations of the PCMH model show promising, albeit inconclusive, outcomes. The integrated PCMH model offers a practical road map for deploying a management system that will enable objective measurement of PCMH performance and outcomes.

Conclusion

Although the jury is still out on the ultimate value of the PCMH, deploying an integrated PCMH system can help position PCMH pilots in a way that enhances their flexibility and scalability to support full-scale network transformation.

Your thoughts and comments on this ME-P are appreciated. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

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Health Industry Collaboration and e-Patients

More on Inter and Intra Healthcare Stakeholder Relationships 

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According to Jennifer Tomasik MS [jtomasik@cfar.com], writing in the soon to be released ME-P textbook from iMBA Inc www.MedicalBusinessAdvisors.com: “Healthcare Organizations” [Management Strategies, Tools, Techniques and Case Studies], now in-process from (c) Productivity Press for 2012:

We are in a time of great change in healthcare. No one is certain how the future landscape will unfold, but it is clear that changes in regulation, reimbursement, technology, the economy, and science will significantly impact the work of those clinicians and administrators who dedicate their careers to improving patient care.

More Collaboration Needed

Experience has shown that better collaboration between patients and among the many different parts of the healthcare delivery system holds great potential to improve the quality of care and the relationships of those delivering it. It has also shown that the opportunities to improve collaboration are widespread.

Our focus, therefore, should be to introduce and share a selected set of tools that can be used to improve collaboration along several dimensions:

  • Clarifying roles and authority through decision charting,
  • Understanding the “give” and the “get” needed to establish effective alliances through the current state, and
  • Working jointly to establish and test a set of refined expectations through a physician-administrator compact.

Assessment

In the end, improved collaboration can help medical institutions with everything from inter professional productivity, to patient satisfaction to the most critical service of all: caring for patients and saving lives.

Link: http://www.crcpress.com/product/isbn/9781439879900

Conclusion

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The ACO Prescription?

Cure or Disease?

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Accountable Care Organizations are the ACA’s [Obamacare] answer to skyrocketing Medicare costs, but who wins besides the government? Doctors take on the financial risk, and patients could suffer as a result.

Here’s a look at how Accountable Care Organizations could affect the quality of healthcare in the near future. Brought to you by gplus.com

Conclusion

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Reflections on Healthcare and Karate in Finland; etc.

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One Visiting Doctor’s Experience on Healthcare … There and Elsewhere!

[By Dr. David Edward Marcinko; FACFAS, MBA, CMP™]

[Publisher-in-Chiefdr-david-marcinko12]

As readers and colleagues know, I’m a great fan of the Finnish culture, lifestyle and people. I’ve visited the country several times, touring and speaking, meeting with government, academia and local industry leaders and politicians in Helsinki, Tempere, Seinajori, Turku, Oulu and Northern Lapland, among other places; and especially Rovaniemi which is home to the world’s most northern branch restaurant of McDonald’s. Of course, the famed Arktikum there is also very comprehensive museum of arts, science and technology. Every time my wife and I visit, we learn more about the language, the arts and tradition.

Recent Visit to Finland

On our most recent month-long visit to Finland, we were able to visit a Japanese Honbu [karate gymnasium], meet several black-belt Taido karate students, and even take an actual class to stay in shape. I’ve been an avid runner for more than 30 years so aerobic cardio-vascular output was not-problematic. The trip was also remarkable for the many insights into the challenges of the Finnish healthcare system, their plans for eHRs and their emerging interest in American medical care. I’ve also made several friends and new colleagues, ingested cold raw dead-fish stew, and mastered the Finnish railway system. And so, my national healthcare service impressions follow; along with a bit more about the art and science of Taido styled karate.

Taido in Finlandkarate-mac

Prior to our departure, we asked my daughter’s karate instructor, Sensei Uchida in Atlanta, GA, about the possibility of attending a Taido work-out in Finland. We were surprised when he informed us that the country has the largest number of Taido students in the world, second only to Japan. This interesting fact was later confirmed by the Finnish Athletic Association. The reason is that this form of exercise is covered under the country’s national health insurance system and is available to all citizens, free of charge. But, of course, income taxes are very high.

In fact, we learned that just the city of Helsinki itself, had nine Honbu’s to choose from and we selected what proved to be the most interesting, indeed! Another American instructor, Sensei Brent, mentioned that he visited the country a few years ago and still has some Taido friends from there, too.

The Taido Karate Honbu

Built during World War II to protect the population living in the City of Tempere from bombs, the Gymnasium in North East Helsinki is built into the side of a huge granite mountain, not unlike our own Stone Mountain here in Atlanta. Since it was originally constructed as an air-raid shelter during WW II, with many snaking corridors and smaller caverns, it is cool all year round with many miles of tunnels maintaining an even 56 degree temperature, just like natural underground caves. No air conditioning is needed for the short summers, and no heating system is needed for the very long winters.

Enter the Health Gymnasium

As we entered the “Health Gymnasium” as it was known, it was as if we were walking into a long tunnel through the woods, about 100 yards long. This entrance to the bomb shelter was really a railroad track line that was still visible after all these years. It was guarded by two huge iron doors several stories high. Inside, was a general reception area where we were directed to the actual Taido Honbu, itself, known as Budo # 6. As we walked through the long winding corridors, we noted that the walls were solid granite, painted white, and that each studio was separated only by a color-coded curtain; much like long rows with individual partitions. There was no graffiti and, although there was no sound-proof protection, the entire Gymnasium was surprisingly quiet.

A Linguistics Error

As we walked along, we noted studios for fencing, gymnastics, boxing and kickboxing, table tennis, ballet, weight lifting, volleyball, rowing and many different types of Karate and other martial arts, like Aikido, Bando Thaing, Capoei, Gatka, Hapkido, JuJitsu, Judo, Kendo, Kung Fu, Sumo and of course Tai Kwon Do. But alas, no Taido Honbu! We were horrified. Did we make a linguistic error! Was the term Taido misinterpreted as a generic terms for all these others types of martial arts or Karate forms? My daughter Mackenzie’s enthusiasm was crushed [after seven years of intensive study, with both national and international competition] as she is a black-belt candidate still in need of some teaching and karate internship credits to reach her ultimate goal. After-all, she brought her Gi [uniform] a long way to not to be able to use it. So, back to the reception area we went, inquiring again in our rudimentary Finnish. Fortunately, the problem was not a language faux-pau at all, but a one of timing. In our excitement, we had merely arrived an hour too early. Soon, the sign on one of the larger partitioned studios was changed to “TAIDO”, and students began filling-in, talking, laughing and giggling before class, just like they do in Atlanta.

Teaching Introductions

The class was comprised of blue, green and brown belt student [there are eight belt ranks], even though we took care to register for the same rank as daughter, Mackenzie. But, it was for about a dozen young adults, ages 18-30, and evenly split between guys and gals! No children. One student had been taking classes for about two years (she averaged 3-4 classes per week), while another was in his ninth year (able to participate only about once or twice per week). Nevertheless, Mac was agreeable to work-out with the adults, under the leadership of Sense Arie, who spoke English and was very cordial to us. When he then asked us what we had learned, we quickly listed Untai, Sentai and Hentai hokis [ritual movements; a Hoki is a pattern of techniques originally put together for mental and physical health and as a practice form of “free fighting.”], as he replied, “that will be sufficient for today”. No doubt, he and the other students were as curious about us, as we were about them. Introductions were made to all students, including moms, dads, grand-moms and grand-dads. We then settled down to watch Mackenzie and the class.

Class Comparisons

Like the Finnish healthcare system, the Taido karate class itself had several similarities and several differences compared to what we are used to, in Atlanta, GA.

1. First, the students and instructors wore the same colored GIs; solid black pants with roughly woven white tops. The GIs also were fancier with many epilates, patches and insignias. The belt color-coded system of the States was not used. Shoes were left outside, all bowed as a sign of respect upon entry, and lined up according to rank. There were no mirrors, horizontal warm-up bares, and virtually no padding in the mats on the floor! The epithet OUS, was replaced by a loudly shouted, EEEE!

2. Second, it was a longer class; an hour and a half, with a ten minute break in-between. Warm-ups were also longer and a bit more strenuous and aerobic orientated; running backwards, sideways and with lunges often performed in-between the hoki’s.  But again, this was an adult class.

3. Third, the class was subdivided into smaller groups like our own, to practice kicks and punches initiated by sound or hand movement, as reaction-time was tested and improved. Mac’s partner had to kneel for her to reach his out-stretched hands, and she in turn had to raise her hands high overhead, as palms were used as targets. Her older partner worked with great diligence to best his younger opponent.  

Finally, the ritualized hoki’s terminated a bit differently than our own, and they were performed much more slowly; almost ritualistically and with great concentration. And, form was a bit more casual than what were are used to, and not as sharp or precise as American Sensei Uchida or Sensei Matsuaki usually demands. 

Health Status of Finlandersfinnish-american-students

Health services are available to all in Finland, regardless of their financial situation. Public health services are mainly financed from tax revenues. The child mortality rate in Finland is one of the lowest in the world; the infant mortality rate is below 4% and the life expectancy for a girl born now is 81 years, for a boy it is 73 years. Much like the US, the life expectancy of Finnish men has deteriorated by cardiovascular disease, excessive consumption of alcohol and accidents. Cardiovascular mortality has declined in response to effective health and nutritional education in recent decades but excessive blood cholesterol levels and obesity remain common in Finland. Smoking and drug abuse are significantly less frequent in Finland than in Europe on average. But, alcoholism and depression are national concerns because of the dark, prolonged and harsh winter climates. The aim of Finnish health policy is to lengthen the active and healthy lifetimes of citizens, to improve quality of life, and to diminish differences in health between population groups. Prevention receives particular emphasis in primary health care.

Finnish Healthcare System

The larger health care system in Finland is attracting international attention. For example, the European Observatory on Health Care Systems just launched a report examining Finland’s health system alongside that of other European countries. The system also has certain special features compared with systems in other countries. The main responsibility for organizing and financing health care is delegated to 448 local municipalities, which have exceptionally small and homogenous population bases, by US comparison. Another special feature is the existence of parallel financing and delivery systems alongside the municipal service system. The Finnish health care system survived the severe economic crisis of the 1990s fairly well, even though marked cuts were made in many public-sector budgets. As a result, it has emerged stronger today. The quantity and quality of health care services were largely maintained by improved management, efficiencies, electronic connectivity and resource allocation. A number of other initiatives are now developing in different directions.

Finnish Medical Association

On a more grass-roots level patient-care basis, the Finnish Medical Association [FMA] collaborates with various authorities and decision-making bodies in relation to the development of personalized medical care in Finland. It pursues patient initiatives and issues a number of statements each year with the aim of improving health care and related legislation, and puts forward plans to ensure a sound financial basis for provision of health services. For example, the national strike by physicians in 2001 drew national attention to the critical lack of resources provided for health care. The FMA plays a significant role in establishing a general patient insurance scheme and developing a family-doctor [US medical-home concept] system for Finnish health centers and practitioners. The Association promotes the rights of patients to have access to the treatment they need promptly. But, the possibilities for choosing a doctor and place of treatment need to be improved.

Contemporary Profile of a Health System in Transition

The Finnish healthcare system, much like the domestic healthcare system, is undergoing a period of reflection, modernization and reform. A special report, known as the Health Care Systems in Transition (HiT) series, profiles and analyzes the health care systems of over 40 European countries, Australia, Canada and the USA. The report for Finland was written by Ms Jutta Järvelin, Researcher at STAKES (the National Research and Development Centre for Welfare and Health), and in collaboration with the Finnish Ministry of Social Affairs and Health and the Observatory. STAKES is a center of expertise overseen by the Ministry of Social Affairs and Health.

On Finnish Longevity

Finnish super-centenarian Aarne Armas “Arska” Arvonen, the oldest Finnish male ever, just passed away at age 111 on January 1, 2009. He was the last living person in Finland who was born in the 1890s, and the third oldest man in Europe. He was also the seventh oldest man in the world. At the time of his death, Aronen was considered among the 20 oldest verified men to have ever lived in Europe.

Assessment

The formal report, Health Care Systems in Transition – Finland [Vol. 4, No 1. 2002]; Copenhagen, European Observatory on Health Care Systems, 2002 is available on the European Observatory on Health Care Systems website:

www.observatory.dk

http://www.euro.who.int/document/e74071.pdf

The report can also be ordered from the European Observatory on Health Care Systems, WHO Regional Office for Europe, Scherfigsvej 8, DK-2100 Copenhagen, Denmark, tel. +45 39 17 1363, fax +45 39 17 1818.

e-mail: observatory@who.dk

And, additional more current information can be obtained from:

Researcher Jutta Järvelin

STAKES, tel. +358 9 3967 2254

e-mail: jutta.jarvelin@stakes.fi and,

WHO e-mail: vge@who.dk

Conclusion

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Is Informatics the The Curse of Healthcare Reform?

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Medical Coding Complications and Greed

[By Darrell K. Pruitt DDS]

Coding complications in government healthcare ALWAYS favor the house — CMS guarantees it with lawsuits and whistleblower rewards that could attract dishonest employees. Are you careful who you hire?

Complications 

Complications in healthcare informatics – including 5-digit CPT® code mistakes as well as foul-ups that involve physicians’ “voluntary” 10-digit National Provider Identifier numbers – ALWAYS grant insurers more time to pay past-due bills owed to their clients and their clients’ doctors.

Call me Cynical 

Call me cynical, but if interest rates climb ever higher as predicted, watch for unexplained, proportional increases in coding errors to help fund insurance CFOs’ bonuses while raising the cost of healthcare even more without improving value. Is it any wonder why Americans don’t get the quality of healthcare we purchase compared to citizens in other countries? Tax-payers in my neighborhood are begging for in-network providers who put their patients’ interests ahead of insurers’ as much as allowed by insurers’ self-serving rules – without committing fraud. As a general rule, healthcare stakeholders accommodate parasites more than principals.

CPT® Codes and Patient Care 

Accurate CPT® coding may have nothing to do with patient care, but CMS makes it nevertheless important to physicians. Whereas the most innocent NPI foul-ups reliably delay payment and never turn out well for providers, the new fraud and abuse provisions of the Patient Protection and Affordable Care Act [ACA] can cause an innocent coding mistake on a Medicare claim to land the doc in court with charges of fraud depending on the quality of employees one hires – but only if the error favors the provider and not the payer. In June, David Burda posted “Attorney tells audience to brace for a storm of whistle-blower lawsuits” on ModernHealthcare.com.

http://www.modernhealthcare.com/article/20100623/NEWS/306209989/-1

Of Whistle-Blower Lawsuits

Burda reports that healthcare attorney Joanne Judge, a partner with Stevens & Lee in Reading, Pa., predicts a significant increase in whistle-blower lawsuits simply because the new law makes it far too easy for a dishonest employee to file an unwarranted lawsuit. No longer is there a requirement for the whistleblower, who stands to win money from his or her patriotic effort, to directly witness the crime. That kind of idea could catch on in this economy.

computer-hardware1

“The new law also converts accidental Medicare overpayments to providers into potential false claims, Judge said. She said the law considers an overpayment as fraud if the overpayment isn’t identified by the provider and returned to the government within 60 days. Judge said that will require providers to beef up their internal billing systems to detect an overpayment as soon as possible and then send Medicare back its money.”

Assessment 

What can possibly go wrong with that plan? Thorough background checks on all new employees is increasingly important, doc. For my employment security issues, I’ve learned to depend on Richard at Investigation Resource Service out of Dallas. He’s never let me down (This is not a paid ad).

Conclusion

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Update on How Physicians Get Paid in 2010-11 [A slide show]

Part 2: [A Visual .ppt Presentation]

By Dr. David Edward Marcinko; MBA

[Editor-in-Chief]

From prior posts and comments on this ME-P, we know that most patients don’t have a clue about how doctors get paid in the real world of health insurance reimbursement.

A Popular Topic

We know this because prior posts on the topic have consistently been among the most popular on this platform. For example:

Part 1: https://healthcarefinancials.wordpress.com/2008/09/12/how-doctors-get-paid

Assessment

And so, we have taken the liberty of drilling down the topic, to a more granular level, in this attached .ppt presentation.

Link: How Doctors Get Paid in 2010 

Conclusion

And so, your thoughts and comments on this ME-P special presentation are appreciated. Tell us what you think?

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David B. Nash MD MBA FACP

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Hospitals & Healthcare Organizations

FOREWORD 

David Nash MD MBA

It should come as no surprise to our readers that the nation faces a financial crisis in healthcare. 

Currently, the United States spends nearly 16% of the world’s largest economy on providing healthcare services to its citizens.  Another way of looking at this same information is to realize that we spend nearly $6,500 per man, woman, and child per year to deliver health services.  And, what do we get for the money we spend?  

This is an important policy question and the answer is disquieting.  Although the man and woman on the street may believe we have the best health system in the world, on an international basis, using well-accepted epidemiologic outcome measures, our investment does not yield much!  

According to information from the World Health Organization and other international bodies, the United States of America ranks somewhere towards the bottom of the top fifteen developed nations in the world, regarding the outcome in terms of improved health for the monies we spend on healthcare. 

From a financial and economic perspective then, it appears as though the 16% of the GDP going to healthcare may not represent a solid investment with a good return. 

It is then timely that our colleagues at the Institute of Medical Business Advisors, Inc. have brought us their greatest work: Healthcare Organizations: [Financial Management Strategies]; a two-volume set of nearly 1,200 pages.  

Certainly, this comprehensive manual, and its quarterly updates, is not for everyone. It is intended only for those executives and administrators who understand that clinics, hospitals and healthcare organizations are complex businesses, with advances in science, technology, management principles and patient/consumer awareness often eclipsed by regulations, rights, and economic restrictions.  Navigating a course where sound organizational management is intertwined with financial acumen requires a strategy designed by subject matter experts. Fortunately, Healthcare Organizations: [Financial Management Strategies] provides that blueprint.

Allow me to outline its strengths and put it into context relative to other policy works around the nation. 

For nearly two years, the research team at iMBA, Inc., has sought out the best minds in the healthcare industrial complex to organize the seemingly impossible-to-understand strategic financial backbone of the domestic healthcare system.   

The periodical print-guide is organized into two volumes in order to appropriately cover many of the key topics at hand.  It has a natural flow, starting with Competitive Strategy and moving through Asset Management, Cost Management, and Claims Management.  

Volume 1, most especially the Competitive Strategy section, has broad appeal and would be of interest to most people in the health insurance industry, including managed care, hospitals, third party benefit managers and the pharmaceutical industry. 

Volume 2 continues in a well-organized theme, progressing from Risk Management and Compliance to Health Policy, Information Technology, and most importantly, Financial Benchmarking. 

Volume 2 would be of greater interest to those in the policy sphere, both in Washington, DC, in state legislatures, consulting companies, medical colleges, and graduate schools of health administration, public health and related fields. Every day colleagues ask me to help explain the seemingly incomprehensible financial design of our healthcare system.  These two volumes would go a long way toward answering their queries. 

I also believe both volumes would be appropriate as text books and reference tools in graduate level courses taught in schools of business, public health, health administration, and medicine. 

In my travels about the nation, many faculty members would also benefit from the support of these two volumes as it is nearly impossible, even for experts in the field, to grasp all of the rapidly evolving details. 

On a personal level, I was particularly taken with the Competitive Strategy section and it brought back enjoyable memories of my work nearly twenty-five years ago at the Wharton School, on the campus of the University of Pennsylvania.  There, I was exposed to some of the best economic minds in the healthcare business and it was a watershed event for me forming some of my earliest opinions about the healthcare system. 

I also very much enjoyed the section on Health Policy, most especially, the section on the Sarbanes-Oxley Act for hospitals and healthcare organizations.  I believe we have not fully embraced the comprehensive nature of Sarbanes-Oxley on the hospital side, and envision a day when hospital boards will be held accountable for quality, in the same way that proprietary corporations are held accountable for the strength and comprehensiveness of their audit reports. Simply put, Sarbanes-Oxley for quality is around the corner and this volume goes a long way toward preparing our basic understanding of the Act and its potential future implications. Congratulations to all authors, but this one in particular deserves specific mention. As a board member for a major national integrated delivery system, I am happy that there appears to be a greater interest in the intricacies of Sarbanes-Oxley on the healthcare side of the ledger. 

In summary, Healthcare Organizations: [Financial Management Strategies] represents a unique marriage between the Institute of Medical Business Advisors, Inc., and its many contributors from across the nation.  As its mission statement suggests, I believe this massive interpretive text carries out its vision to connect healthcare financial advisors, hospital administrators, business consultants, and medical colleagues everywhere. It will help them learn more about organizational behavior, strategic planning, medical management trends and the fluctuating healthcare environment; and consistently engage everyone in a relationship of trust and a mutually beneficial symbiotic learning environment.  

Editor-in-Chief and healthcare economist Dr. David Edward Marcinko and his colleagues at the Institute of Medical Advisors, Inc should be complimented for conceiving and completing this vitally important project. There is no question that Healthcare Organizations: [Journal of Financial Management Strategies] will indeed enable us to leverage our cognitive assets and prepare a future generation of leaders capable of tackling the many challenges present in our healthcare economy.  

My suggestion therefore, is to “read it, refer to it, recommend it, and reap.”  

David B. Nash MD, MBA
The Dr. Raymond C and Doris N. Professor and
Chair of the Department of Health Policy
Jefferson Medical College
Thomas Jefferson University
Philadelphia, Pa, USA
 

Conclusion

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The Death of Medical Practice? [A Voting Poll and Survey]

Has Demise been Greatly Exaggerated?

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By Staff Reporters

QUESTION: Are solo practitioners, and small group physician medical practices, on the verge of disappearing?

In our businessmodel, some pundits opine that:

“Primary care physicians and other specialists will continue to be the target of acquisitions by larger health and hospital systems. Physicians will begin to transition to a more consumer-based patient orientation model (i.e. concierge medicine, cash-for-services, retail) in order to replace lower reimbursements, or opt out of third-party reimbursement models entirely. Or alternatively, these physicians will shift to become an employee of a larger system.”

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At Your Next Medical Management, Pharma or Financial Services Seminar  

Our Editor-and-Chief, Dr. David Edward Marcinko MBA CMP™ is a former medical practitioner and board certified surgeon [FACFAS], certified financial planner, stock-broker, insurance agent, Registered Rep, RIA representative, writer, editor, journalist, expert witness and healthcare economist who enjoys public speaking and gives as many talks each year as possible, at a variety of medical society, pharmaceutical and financial services conferences around the country and world.

Many Venues

These have included lectures and visiting professorships at major academic centers, keynote lectures for hospitals, economic seminars, pharma conventions and health systems, endnote lectures at city and statewide financial coalitions, and break-out lectures for a variety of internal and external yearly meetings.

Assessment

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The Medicare Cost-Control Efficiency Paradox

Essay on the Eight-Hundred Pound Gorilla in the Medical Treatment Room

By Dr. David E. Marcinko MBA

[Editor-in-Chief]

According to economist Austin Frakt PhD, and others, there is a school of thought that says Congress is incapable of controlling costs in the Medicare and Medicaid System [CMS].

And, then there is the reality known by all practicing medical professionals regardless of specialty orientation or degree designation. That is to say, CMS really can control healthcare costs and with great ferocity and efficiency, and to non-public sectors as well …. PARADOXICAL?

On Getting What You Wish For

Blogger Ezra Klein opines that one of the dirty little secrets of the health-care system is that Medicare has done a much better job controlling costs than private health insurers.

http://voices.washingtonpost.com/ezra-klein/2010/11/what_happens_when_medicare_con.html

A Forehead-Palm Moment

Of course, we doctors know that the real problem is that Medicare seemingly [think Seinfeld’s character George Costanza] controls costs all too well; but not really. It is just that CMS pays doctors too little and thus it appears costs are controlled. What really is happening is that physician fees are being reduced carte’ blanche.

Nevertheless, and regardless of semantics, CMS will never control costs much more efficiently than private insurance companies or doctors will simply abandon Medicare for related payment models like direct reimbursement or concierge medicine. This is happening right now. Physicians, osteopaths and podiatrists etc, are opting out of Medicare in increasingly large numbers. In a world where there’s only Medicare and Medicare to control costs, doctors can either take the pay cut or stop seeing patients, and stop being doctors. “Taking what they are given – because they’re working for a livin.”

So sorry that this seems like a forehead-palm moment for Ezra, but not for healthcare practitioners or the ME-P!

Too Much Demand Elsewhere

And, as we see from other countries, many young bright folks want to be doctors, even if being a doctor doesn’t make one particularly wealthy [high demand and high eventual supply produces lower provider costs in the long term?]. Think medical tourism.

Not so much the case anymore in this country [lower demand and lower eventual supply produces higher reimbursement costs to the doctor survivors in the very long term?].

Our Domestic World

But, we are not elsewhere. In fact, in our present domestic healthcare ecosystem, when Medicare decides to control costs, many doctors can simply stop accepting Medicare patients, and the politicians will lose their jobs. One political party then declares that Medicare is rationing and will hurt senior citizens. The other party capitulates and pays MDs more [SGR]. Then, the federal budget looks bad as it does now. The circle is complete when one party asserts that Medicare actually can’t contain costs but the private insurance companies will.  It all fails, in an unending circular Boolean-like loop of illogic.

Listen Up!

So, listen up AARP, politicians, CMS and seniors as I admonish you to be careful what you wish for [medical cost controls]. It might just come true. As Ezra rightly says; rinse, repeat – rinse, repeat – ad nausea. You simply can’t have it both ways.  You either choose to spend less and offend certain cohorts, or spend more and offend different factions.  Either way, you’re going to piss someone off. A good healthcare reimbursement system would try to make that decision rationally [a-politically]. But, at least it would make an economics driven decision; wouldn’t it?

Assessment

Is CMS really the eight hundred pound cost-controlled gorilla in the increasingly large Medicare treatment room? Why or why not? Now, relative to the ACA of 2010, please read: The Case for Public Plan Choice in National Health Reform [Key to Cost Control and Quality Coverage], by Jacob S. Hacker, PhD. Link: Jacob Hacker Public Plan Choice

Conclusion

And so, your thoughts and comments on this ME-P are appreciated. Do we have a Medicare cost control efficiency paradox? Or, are the economists just reveling in the publication banal? Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

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Is Primary Care Medicine Toxic?

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Requesting Real-Life Examples of Professional Despair

By Dr. David Edward Marcinko MBA CMP™

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[Editor-in-Chief]

As you’ve probably heard – and experienced or know from our books, journal and this ME-P – there’s a primary care medical shortage out-there!  Maybe you’ve even read or heard about the Physician’s Foundation study describing the overwhelming number of PCPs who want out of this toxic environment. On one hand, we have patients desperately searching for a PCP, while on the other hand we have good caring doctors being forced out of the profession. Of course, NPs, ANPs, DNPs and other ancillaries are part of the solution; but not entirely.

Link: http://www.physiciansfoundation.org/

Human Anguish

And humanely, as stated by our medical colleague L. Gordon Moore MD, these statistics miss the very real pain and anguish of people who entered primary care to help patients when they find the environment for primary care toxic to the ethical practice of medicine. Even to the point of suicide!

Assessment

These voices need to be heard. And so, we are asking doctors and providers of all stripes to post in the comments section below personal examples of medical practitioners leaving primary, solo or small group practice because they just can’t stand the toxic environment any longer.

Conclusion

Your thoughts and comments on this ME-P are appreciated. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

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Dental Therapists [Emerging New Providers?]

Coming to a State Near You

By D. Kellus Pruitt DDS

The topic of the day in the dental industry concerns the recent WK Kellogg Foundation announcement of their $16 million initiative to help dentalcare stakeholders in five U.S. states, including Kansas and New Mexico, develop dental therapist programs similar to Alaska’s experiment in low cost – high risk dentalcare. The project is moving forward because of reportedly excellent results in a 2 year study following 5 therapists who are a couple of years out of high school with 400 hours of training and 300 Alaskan patients in hard to reach places. That’s risky even in the best of conditions in better climates. It doesn’t take many tragedies to eat up the savings from cheap.

A Balanced Article

DrBicuspid.com contributing writer Mary Otto posted a balanced article on the topic titled “More states moving forward with midlevel providers.”

http://www.drbicuspid.com/index.aspx?d=1&sec=sup&sub=pmt&pag=dis&ItemID=306190

In My Opinion

I am very pleased to see ADA President Dr. Raymond Gist making his presence known concerning the dental therapist controversy. At last count, his name has come out on the Internet four times since yesterday – even though the ADA had to pay a lot of money for the press releases. If dentists fail to represent the interests of dental patients, nobody else will.

Assessment

Paid advertisement is not as effective and not as cheap as an ADA Facebook would be, but press releases are certainly better than silence from ADA President Dr. Raymond Gist.

Conclusion

And so, your thoughts and comments on this ME-P are appreciated. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too! Then, subscribe to the ME-P. It is fast, free and secure.

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On the Texas Health and Human Services Commission’s Legislative Appropriation for Dental Plans

Fair Warning – Texans

By Darrell K. Pruitt DDS

Just like capitation dental plans, in the long run, poor, sick children in hospitals don’t save Texans money

THHS Commission’s Legislative Appropriation

As part of the Texas Health and Human Services Commission’s legislative appropriation request, the Agency is quietly pushing for approval of a short-sighted proposal to change the state’s current Medicaid/CHIP (discounted) fee-for-service delivery model to multiple corporate-run capitation plans – where executives who fund political campaigns get bonuses but cannot be held accountable for the slow lines or the fast dental work.

Expedient Deception?

If HHSC succeeds in their politically-expedient deception, not only will it be even more difficult for poor parents to find dentists who accept Medicaid or CHIP payment, but the communities’ charity dental clinics – the default hope of relief for far too many of the state’s poor already – will be unable to keep up with the surge of basic dental needs in the community. Many free dental clinics already need donations of dentists’ free time more than money.

Current Programs Marginally Acceptable 

Even though the state’s current Medicaid/CHIP program is only marginally acceptable to dentists because of next to charity fees plus aggravating and costly bureaucracy, nothing is more disgusting with dentists and patients than dental managed health organizations (DMHO). If naïve people in Austin have their way, the long waits for dentists’ time – state-paid or volunteer – will increasingly cause children to end up in hospital emergency rooms with painful, life-threatening oral infections that are expensive and preventable.

Assessment 

Your local dentist’s capacity to give back to your community by volunteering in neighborhood free clinics is not limitless. Let’s not make a bad situation worse with capitation. It’s a lie.

Conclusion

And so, your thoughts and comments on this ME-P are appreciated. The time is NOW to contact YOUR TEXAS LEGISLATOR http://www.fyi.legis.state.tx.us/ and tell them a capitated dental managed care delivery model is not in the best interest of Texas children or Texas dentists! Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

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Useful Managed Care Provider, Staffing, Activity and Financial Trends

Part Two

By Dr. David Edward Marcinko MBA

[Publisher-in-Chief]

Dr. DEMIf you read this ME-P regularly or have read my earlier blogs, you know that I am writing a book on practice management for the private medical practitioner.

The Business of Medical Practice [Transformational Health 2.0 Skills for Doctors]; third edition: www.BusinessofMedicalPractice.com

Link: Front Matter BoMP – 3

A recent story in the Chicago Tribune on the difficult business life of private practitioners today reminds me that I need to keep my nose to the grindstone.

For example, according to the sanofi-aventis Pharmaceutical Company Managed Care Digest Series, for 2008-10, the following patterns and comparative trend information has been empirically determined and may provide a basic starting point for medical practitioners to share business management, facilities, personnel, and records information for enhanced success www.managedcaredigest.com

Mid-Level Provider and Staffing Trends

  • Mid-level provider use increased among multi-specialty groups, especially in those with more than half of their revenue from capitated contracts. Use also rose with the size of the practice and was highest with OB/GYN groups.
  • Medical support staff for all multi-specialty groups fell and was lowest in medical groups with less than 10 full-time equivalent (FTE) physicians. However, groups with a large amount of capitated revenue actually added support staff. Smaller groups limited support staff.
  • Compensation costs of support staff increased and the percentages of total operating costs associated with laboratories, professional liability insurance, IT services, and imaging also increased. Support staff costs increase with capitation levels and more than half of all operating costs are tied to support staff endeavors.

Managed Care Activity and Contracting Trends

  • More medical group practices are likely to own interests in preferred provider organizations (PPOs) than in HMOs and the percentages of groups with managed care revenue continues to rise. Multi-specialty and large groups also derive more revenue from MCOs than single specialty or smaller groups.
  • Managed care has little effect on physician payment methods that are still predominantly based on productivity. Physicians were paid differently for at-risk managed care contracts in only a small percentage of cases.
  • Most medical groups (75%) participating in managed care medicine have PPO contracts. Group practices contract with network HMOs more often than solo practices. Single-specialty groups more often have PPO contracts.
  • Capitated lives often raise capitation revenues in large group practices. Group practices are more highly capitated than smaller groups or solo practices. Almost 30% of highly capitated medical groups have more than 15 contracts and 22% have globally capitated contracts.
  • Higher capitation is linked with increased risk contracting. Larger groups have more risk contracting than smaller groups.

Physician Health

Financial Profile Trends

  • Medicare fee-for-service reimbursement is decreasing. Highly capitated groups incur high consulting fees.
  • The share of total gross charges for OB/GYN groups associated with managed care at-risk contracts is rising while non-managed care, or not-at-risk charges are declining.
  • Capitated contracts have little effect on the amount of on-site office non-surgical work. Off-site surgeries are most common for surgery groups, not medical groups.
  • Half of all charges are for on-site non-surgical procedures.
  • Highly capitated medical groups have higher operating costs and lower net profits.
  • Groups without capitation have higher laboratory expenses than those who do.
  • Physician costs are highest in orthopedic surgery group practices. Generally, median costs at most specialty levels are rising and profits shrinking.

Assessment

Obviously, the above information is only a gauge since regional differences, and certain medical sub-specialty practices and carve-outs, do exist.

Part One: Useful Managed Care Patterns and Procedural Utilization Trends

Conclusion

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Useful Managed Care Patterns and Procedural Utilization Trends

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Part One of Two

By Dr. David Edward Marcinko MBA

[Publisher-in-Chief]

If you read this ME-P regularly or have read my earlier blogs, you know that I am writing a book on practice management for the private medical practitioner.

The Business of Medical Practice [Transformational Health 2.0 Skills for Doctors]; third edition: www.BusinessofMedicalPractice.com

Link: Front Matter BoMP – 3

And, a recent story in the Chicago Tribune on the difficult business life of private practitioners today reminds me that I need to keep my nose to the grindstone.

For example, knowing your medical contract negotiation objectives, gathering information on the choices of contracts and discount payment systems, and understanding the pitfalls to watch for when evaluating a contract are the keys to any successful negotiation process.

Reimbursement Contract Negotiations

According to the sanofi-aventis Pharmaceutical Company Managed Care Digest Series, for 2008-10, the following pattern and trend comparative information has been empirically determined and may provide a basic starting point for practitioners to share business management, facilities, personnel, and other records for enhanced contract negotiation success.

www.managedcaredigest.com

hos

Procedural Utilization Trends

  • Among all physicians in a single-specialty group practice, invasive cardiologists averaged the most encounters with total hospital inpatient admissions down from the prior year. However, encounters rose for cardiologists in multispeciality group practices.
  • Echocardiography was the most commonly performed procedure on HMO seniors, followed by coronary artery bypass graft surgery. Group practices performed cardiovascular stress tests for circulatory problems most often.
  • CT studies of the brain and chest were the most common studies for HMO seniors, while MRI head studies were the most common diagnostic test on commercial HMO members.
  • Colonoscopy was the most common digestive system procedure on senior HMO members, while barium enemas were more common on commercial members.
  • Hospital admission volume decreased for allergists, family practitioners, internists, OB/GYNs, pediatricians, and general surgeons.
  • Internists ordered more in-hospital laboratory procedures than any other physicians in single-specialty groups.
  • Non-hospital MD/DOs used in-hospital radiology services most frequently, continuing a three-year upward trend.
  • Pediatricians averaged the most ambulatory encounters, down from the prior year.
  • Non-hospitalist internists ordered a higher number of in-hospital laboratory procedures than any other single medical specialty group, but allergists and immunologists increased their laboratory usage.
  • The number of ambulatory encounters increased for general surgeons, while group surgeons had the most cases. Capitated surgeons, of all types, had a lower mean number of surgical cases than surgeons in groups without capitation. Surgeons in internal medical groups also had more cases than those in multi-specialty groups.
  • The average number of total office visits per commercial and senior HMO visits fell, along with the number of institutional visits for both commercial and senior HMO members.
  • The average length of hospital stay for all commercial HMO members increased to 3.6 days but decreased to 6 days for all HMO members.
  • The total number of births increased for commercial HMO members served by medical group practices, and decreased for solo practitioners.
  • More than one-third of all medical groups use treatment protocols, rising from the year before. Multi-specialty groups were more likely to use them than single-specialty groups, who often develop their own protocols. The use of industry benchmarks to judge the quality of healthcare delivery also increased.
  • Outcome studies are most common at larger medical groups, and multi-specialty groups pursue quality assurance activities more often than single-specialty groups.
  • Provider interaction during office visits is increasingly coming under scrutiny. Patients approve of cardiologists more frequently than allergists and ophthalmologists.

Assessment

Obviously, the above information is only a gauge since regional differences, and certain medical sub-specialty practices and carve-outs, do exist.

Part Two: Useful Managed Care Provider, Staffing, Activity and Financial Trends

Conclusion

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Understanding Hierarchical Condition Category Management for MAPs

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An Emerging Management Trend for Medicare Advantage Plans [MAPs]

By Dr. David Edward Marcinko; MBA, CMP™

[Publisher-in-Chief]

So called Hierarchical Condition Category Management (HCCM) is an emerging healthcare management trend designed to accurately reflect the health status of Medicare Advantage Plan [MAP] members and to help them remain financially viable in Part D of the system.

HCCM Indications

Since the Medicare risk adjustment payment system uses clinical coding information to calculate risk premiums for Medicare Managed Care Organizations (MMCOs), HCCM seems best to address the following:

  • CMS risk adjustment system.
  • Strategic and financial implications for Medicare plans.

Assessment

Any initiatives required to effectively managed care under a risk adjustment payment system is ripe for HCCM and the key success factors associated with these initiatives.

Link: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2936901/

Conclusion

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The Rise of Niche Medical Providers

Understanding New Roles and a Changing Delivery Ecosystem

By Staff Reporters

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It is well know that orthopedic and cardiac hospitals have experienced a development boom over the past decade.  And, according to Robert James Cimasi MHA, AVA, CMP™ of Health Capital Consultants, LLC, reimbursement levels for these specialties, and especially surgeries, have been considered to be relatively high in comparison to others, creating the perception that these services are especially profitable.

Reasons for Development

The reasons for specialty hospital development are complex and vary across markets but analysis suggests that three factors are important drivers of this trend nationally:

  • relatively high reimbursements for certain procedures;
  • physicians’ desire for greater control over management decisions affecting productivity; and ,
  • quality and specialists’ desire to increase their income in the face of reduced reimbursement for professional services.

Perspectives

From the perspectives of some observers, the possible “overpayment” for certain specialties’ services is unintentional on the part of payors and is possibly the result of recent productivity gains in those specialties.  The promoters of this reimbursement methodology have asserted,

The challenge for policy makers is to give specialty hospitals the chance to fulfill their promise as focused factories while limiting their opportunities to prosper from cream skimming and preventing problems for patients and communities such activity might cause.

From this singularly preconceived viewpoint, productivity gains through efficient provision of quality services should be discouraged and saddled with the disincentives of lower reimbursement to allow less efficient providers to compete.  That surgical and specialty hospitals focus on a narrower range of procedures and produce quality and efficiency gains over their general acute care hospital competitors is rarely disputed.  Existing hospitals often admit this but then claim that new market entrant hospitals dilute the experience level of their facilities, which then results in a lowering of quality.  This is part of the larger argument that any quality or financial gains made by the surgical or specialty hospitals are the direct result of losses at the general acute care hospitals.  If these hospitals can’t cost shift to subsidize less profitable areas such as emergency departments and intensive care units, the argument goes, then they will be in jeopardy of closing them.

Medical Professionals and ME-P Advisors

Proponents

These proponents assert: “Policy makers seek to encourage competition and give new care delivery models that have the potential to improve quality and lower costs a chance.  However, they also want to maintain quality and patient safety, avoid total as well as per-case cost increases and preserve access to basic services.”

Assessment

In response to the development of niche providers and specialty hospitals, general acute care hospitals often are competing by adding to their offerings in these specialties to create integrated specialty centers or even constructing new specialty hospitals themselves.  In many cases, hospitals seek physician involvement in these developments, through joint ventures or other means.

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Conclusion

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On Delta Dental and the National Association of Dental Plans

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ADA News Tries Sarcasm

[By D. Kellus Pruitt DDS]

For fear of retaliation, ADA officials are reluctant to admit that Delta Dental and other members of the National Association of Dental Plans (NADP) have traditionally used the FTC as a tool to intimidate our professional organization. This means that for decades, the federal government has prevented the ADA from adequately representing the interests of dentist members. Something interesting happened in the ADA just days ago that is related to this tyranny. I assume frustration in the ADA’s unfair struggle against both Delta Dental and the FTC caused the editor of the ADA News to recently permit sarcasm for the first time in history – perhaps to attract attention to Delta’s policies?

A Humorous Article 

On August 9, ADA reporter Kelly Soderlund was given the green light to post an uncharacteristic, tongue-in-cheek introduction to her article, “Decision supports Massachusetts Dental Society insurance challenge.” http://www.ada.org/news/4558.aspx She sold it: “For nearly 40 years, Massachusetts dentists have had to abide by a regulatory order that allowed Delta Dental Plan of Massachusetts to receive an additional 5 percent discount off reimbursement fees in addition to other plan discounts.” Soderlund continues, “More than a decade ago, the Massachusetts Dental Society tried to get the order lifted but was unsuccessful. But now, after a reinstated five-year battle, the New England dentists can claim victory.”

OK. I lied.

In spite of her unintentionally humorous description of the Massachusetts Dental Society’s ineffectiveness, Soderlund was actually not sarcastic. That’s right. The ADA indeed hails this (very qualified) success as a long-fought glorious victory for dentists in Massachusetts where 95% of them are Delta preferred providers. That can’t be good for the health of Massachusetts dental patients. Managed care dentistry is dentistry by the lowest bidders with no quality control, and patients notice. Some stop going to the dentist, causing Delta Dental to reap even more profit. That is why it is not in Delta’s interest to satisfy their clients, and the employers who purchase Delta’s plans are clueless. This makes Delta Dental unaccountable to anyone.

The Delta Business Model 

Delta’s business model helps make the company one of the most unfair discount dentistry brokers in the nation, in my opinion. If you want proof, go to doctoroogle.com and visit any major city.

http://www.doctoroogle.com/dentist_ratings.cfm/pageID/2 Then compare dental patients’ ratings of Delta’s preferred providers to fee-for-service dentists’. In the numerous studies I’ve performed, Delta’s dentists’ average satisfaction level as determined by their patients is consistently inferior to fee-for-service dentists. (See Managed Care Report Card from November 10, 2008).

http://community.pennwelldentalgroup.com/forum/topics/transparency-and-managed-care?commentId=2013420%3AComment%3A19577

Delta Accountability? 

As you can see, since the FTC inhibits the ADA from honestly telling our story, dental care principals desperately need the ADA to open our Facebook so Delta can be held accountable to dentists and patients. Otherwise, Delta will never assume responsibility for the dental homes its preferred provider lists break apart – more often than not, sending their clients to less satisfying offices. What’s more, even Delta officials admit that “changing dentists causes fillings.” (See “Managed Care or Dental Homes – You can’t have both,” September 30, 2008)

http://community.pennwelldentalgroup.com/forum/topics/2013420:Topic:14014

FTC Fear 

If dentists and patients are not permitted to tell our story ourselves through the nationally recognized American Dental Association, we will always be 40 years behind Delta Dental and 5% short of what they owe us. Even though ADA leaders will forever be handicapped by fear of the FTC, individual Americans have nothing to fear. The failure of the Massachusetts Dental Association shows us that an ineffective ADA is worse than no ADA at all because a victory after 40 years is defeat.

MDA Victory 

One can read from Soderlund’s words that the Massachusetts Dental Association’s “victory” didn’t even slow Delta down. She writes “Delta Dental of Massachusetts has informed the ADA that the new reimbursement methodology will include the development of regional fee schedules. Information on exactly how those regional fee schedules will be developed and how that will affect dentists’ reimbursement has not yet been made available.” Whatever methodology Delta’s actuaries come up with, you can be sure it will be biased against their clients’ interests and will more than make up for the 5% of principals’ money that they conceded after 40 years. We simply must face the fact that the ADA isn’t helping. Soderlund continues: “The company also announced a new voluntary program to compensate dentists for successfully managing the care of higher risk patients. Delta Dental has not yet explained how that compensation would take effect.”

Assessment

Do you trust a Delta Dental consultant – who works on commission – to decide what is best for your patient? Or are you ready to demand that the ADA open our Facebook so we can all tell Delta Dental what we think of their unfair practices on an individual basis guaranteed by the First Amendment? Our patients depend on us to protect them from harm caused by greedy stakeholders. As Soderlund describes it, we’re losing, but not without humor.

Conclusion

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On Hospital Revenue Cycle Opportunities

Do They Still Exist in Today’s Healthcare Milieu?

Staff Reporters

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For a decade now, healthcare providers have been challenged to deliver quality patient care in an environment of shrinking profit margins. Total margins and operating margins have followed the same trend. Analysts report that an operating margin of less than 5% leaves an organization without the resources to invest in new technology and capital projects, and will eventually force the facility to close or merge. With rising labor costs, a poorly performing economy, and an aging population, these numbers are not likely to improve soon.

Bar code use in hospitals may save lives

Industry Status

Although the industry has seen an overall improvement in accounts receivable days and bad debt for an extended period, it appears that many facilities have reached their peak in addressing these areas, particularly given current demands to reduce staff and other operational costs. So, where is the next major opportunity for reducing costs or maximizing revenue opportunities?

The Experts Opine

According to private consultants Ross J. Fidler and Karen White PhD, revenue cycle improvement still seems to be a promising and popular area today. And, PriceWaterhouseCoopers recently listed five areas to reinvent the revenue cycle:

1) organizational / accountability;

2) process/workflow improvements;

3) information systems/management reporting enhancements;

4) quality assurance mechanisms; and

5) department and staff productivity measurements.

Assessment

A thorough re-examination of the revenue cycle process will typically uncover cost drains and revenue opportunities.

Conclusion

To succeed in enhancing hospital revenue streams, for example, we commence with patient access through HIM to PFS, by applying optimal organizational structures, benchmarking, and technology adoption. Only then will outcomes trend toward higher performing revenue cycles.

And so, your thoughts and comments on this ME-P are appreciated. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

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About the Managed Care Digest Series

Creating Custom Data Reports for Chronic Diseases

By Staff Reporters

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The sanofi-aventis Managed Care Digest Series online resource for Chronic Disease Information is part of their continuing commitment to provide the latest most essential information on the evolution of health care. The Series, available online or in print, provides key benchmarking data that can help assess value, control costs, and develop business strategies.

Updates

Updated information is available. Just keep looking for Digest Bytes from the team at the Managed Care Digest Series

Assessment

For step-by-step instructions please review their Articulate Presenter.

Conclusion

And so, your thoughts and comments on this ME-P are appreciated. Give em’ a click and tell us what you think? Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

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Current Outlook for the Hospital Industry

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Adaptation is Key in 2010 and Going Forward

By Robert James Cimasi; MHA, ASA, AVA, CBA, CMP™

cimasi

www.HealthCapital.com

Hospitals today must continually adjust to deal with pressures to contain reimbursement and utilization levels.  The continuing cost containment pressures manifest themselves in many patients being shifted not only to lower acuity treatments but also to other providers.

Reimbursement mechanisms are increasingly designed to control costs and access. Managed care insurance plans continue to be a strong influence as payers for acute care hospital services. Medicare’s HOPPS [hospital outpatient prospective payment system] has reduced many of the financial benefits of shifting more care to outpatient settings.

Personnel Shortages

Personnel shortages have plagued the industry, and with the pending retirement of baby-boomers, relief from these shortages seems remote. This population also heavily influences the consumer side of the industry, since healthcare plans are based heavily upon demographics.  Aging baby-boomers are the fastest-growing segment of the population; the portion of the population over 65 years old is expected to increase from 20 million in 1970 to 69.4 million in 2030. Following closely behind is the increase in other minority populations.  Both groups will influence how healthcare services are dispensed.

Additionally, despite pressure to limit ALOS [average length of stay] and the shift to outpatient and freestanding, off-campus care, there will continue to be demand for acute care hospitals and the demographic trends will support this demand for many years.

Technology

Technological advances always play a central role in changing the medical industry.  The issue will be how healthcare providers will adopt new technologies under their current capital constraints.

Currently, health care insurance coverage is a major unfolding issue in the US, and there remains uncertainty about the future level of both public and private insurance coverage.  Now, facing the recent economic instability, employers are looking at restraining healthcare benefits for their employees even more as a way to stay profitable.

Assessment

The decline in the healthcare workforce coinciding with the increase in labor costs and resource consumption poses an ongoing challenge.  And yet, in the midst of the economic turmoil, hospitals must continue to provide services while remaining aware of the economic threats that may still lie ahead.

More:

Conclusion

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Implementation of the Healthcare Deficit Reduction Act

Signed by President Bush in 2006

By Gregory O. Ginn; PhD, MBA, CPA, MEd

By Hope Rachel Hetico; RN, MHA, CMP™

The Deficit Reduction Act (DRA), S. 1932, was signed by President Bush on February 8, 2006, and became Public Law No. 109-171.  Implementation of the act includes these provisions:

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Subtitle A – Provisions Relating to Medicare Part A

  • hospital quality improvement (section 5001);
  • improvements to Medicare-dependent hospital (MDH) programs (section 5003);
  • reduction in payments to skilled nursing facilities (SNFs; section 5004);
  • phase-in of inpatient rehabilitation facility classification criteria (section 5005);
  • development of a strategic plan regarding investment in specialty hospitals (section 5006);
  • demonstration projects to permit gain-sharing arrangements (section 5007); and
  • post-acute care payment reform demonstration programs (section 5008).

Subtitle B  Provisions Relating to Medicare Part B

  • title transfer of certain durable medical equipment (DME) to patients after 13-month rental (section 5101);
  • adjustments in payment for imaging services (section 5102);
  • limitations on payments for procedures in ambulatory surgical centers (ASCs; section 5103);
  • minimum updates for physician services (section 5104);
  • three-year extension of hold-harmless provisions for small rural hospitals and sole community hospitals (section 5105);
  • updates on composite rate components of basic care-mix adjusted prospective payment systems (PPS) for dialysis services (section 5106);
  • accelerated implementation of income-related reductions in Part B premium subsidy (section 5111);
  • Medicare coverage of ultrasound screening for abdominal aortic aneurysms; National Educational And Information Campaign (section 5112);
  • improvements to patient access and utilization of colorectal cancer screening under Medicare (section 5113);
  • delivery of services at federally qualified health centers (FQHC) (section 5114); and
  • waiver of Part B Late Enrollment Penalty for certain international volunteers (section 5115).

Subtitle C – Provisions Relating To Parts A and B

  • home health payments (section 5201);
  • revision of period for providing payment for claims that are not submitted electronically (section 5202);
  • timeframe for Part A and B payments (section 5203); and
  • Medicare Integrity Program (MIP) funding (section 5204).

Subtitle D – Provisions Relating To Part C

  • phase-out of risk adjustment budget neutrality in determining payments to Medicare Advantage organizations (section 5301); and
  • Rural PACE Provider Grant Programs (section 5302).[1]

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The goal of the act is to save nearly $40 billion over five years from mandatory spending programs through slowing the growth in spending for Medicare and Medicaid. Has it been successful to-date?

Assessment

We know from personal experience that the DRA can be implemented by all healthcare stakeholders to the benefits of the industry sector in the aggregate. But, has it been?

Conclusion

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Editors Note: Gregory Ginn has been a professor in the Department of Health Care Administration at the University of Nevada, Las Vegas, since 2000. He received his doctorate, MBA, M.Ed., and undergraduate degree from the University of Texas at Austin, and is an inactive Certified Public Accountant registrant in the States of Nebraska and Texas. Before his current position at UNLV, he spent time teaching at Clarkson College, College of Saint Mary, University of Findlay, University of Central Texas, Stephen F. Austin State University, State University of New York at Buffalo, University of Houston at Victoria, University of Texas at Austin, and the Southwest Texas State University. Prior to his academic roles, he was an accountant for Touche Ross & Co., and an Internal Revenue Service Tax Auditor. Dr. Ginn has also been a reviewer for organizations such as: Health Care Management Review and the Health Care Administration Division of the Academy of Management. He is Treasurer for the Nevada Executive Health Care Forum and was a member of the Southern Nevada Wellness Council. His graduate teaching experience in healthcare administration is abundant, having taught courses in: Management of Health Services Organizations, Quantitative Methods, The U.S. Health Care System, Health Care Systems and Policy, Health Care Finance, Group Practice Management, Long-term Care, and Health Care Law.  He has been published in numerous journals, including Journal of Healthcare Management, Hospital Topics, Nursing Homes, Journal of Nursing Administration, International Electronic Journal of Health Education, and Hospital and Health Services Administration. His current and former professional memberships include: American College of Healthcare Executives, Nevada Executive Healthcare Forum, Academy of Management, Association of University Programs in Health Administration, Certified Medial Planner (Hon.) and Heartland Health Care Executives.

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Coordination, Switching Costs and the Division of Labor in General Medicine

An Economic Explanation for the Emergence of Hospitalists in the United States

Submitted by Hope Rachel Hetico RN, MHA

[Managing Editor]

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From a white paper by David O. Meltzer, Jeanette W. Chung

NBER Working Paper No. 16040
Issued in May 2010

General medical care in the United States has historically been provided by physicians who care for their patients in both ambulatory and hospital settings.  Care is now increasingly divided between physicians specializing in hospital care (hospitalists) and ambulatory-based care primary care physicians.  We develop and find strong empirical support for a theoretical model of the division of labor in general medicine that views the use of hospitalists as balancing the costs of coordinating care across physicians in the hospitalist model against physicians costs switching between ambulatory and hospital settings in the traditional model.

Assessment

These findings suggest opportunities to improve care.

Link: http://papers.nber.org/papers/w16040

Conclusion

All ME-P readers are invited to opine.

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Celebrating our 1,500th Medical Executive-Post

Even More to Come in the Years Ahead

By Ann Miller; RN, MHA

[Executive-Director]

This ME-P is an information sharing portal for the integrated healthcare industrial complex, medical practice management and financial planning and advisory communities.

We have a search engine to help find essays and follow the breaking news that interests you for this space. Our articles, gossip, videos, books, journals, dictionaries, alerts and related information are continuously updated and ranked by users. 

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And, just recently we’ve celebrated our 1,500th post. Of course, as a participative service, you can publish an article directly on the site or comment on an existing item. You can also vote for an article or a group that captures your interest in order to increase its visibility on the site.

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But, you must be a member to post; so join us today. We’ve come a long way in less than 3 years, with a lot farther to go!

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How to Evaluate a Managed Care Contract Proposal?

ASK AN ADVISOR

To Join -or- Not to Join is the Question

By Staff Reporters

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A new-wave West-Coast managed care organization (MCO) wanted a multi-specialty medical group to contract with them to provide medical services to all subscribers. Compensation would be in the form of a fixed-rate capitated payment system, a.k.a. per member / per month (PM/PM).

Ask an Advisor

The medical group practice administrator reviewed their request for proposal (RFP) very carefully, but is still not sure what to do. So, allow us to “crowd-source” as we ask ME-P readers, advisors and management consultants for a solution.

Key Issues

Facts to know for an informed PM/PM capitated reimbursement decision:

  • annual frequency or service-rate per 1,000 patients
  • unit cost of medical services per unit-patient
  • co-payment dollar amount per patient
  • co-payment frequency rate per 1,000 patients
  • variable cost per patient
  • under-capacity medical group office utilization rates, and
  • fixed overhead office-cost coverage [+/-].

Assessment

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More case models: https://medicalexecutivepost.com/2010/03/12/healthcare-case-models-cd-rom/

Conclusion

And so, your thoughts and comments on this ME-P are appreciated. What is your solution; accept or reject the contract proposal? Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, be sure to subscribe. It is fast, free and secure.

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Healthcare Organizations: www.HealthcareFinancials.com

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Physician Advisors: www.CertifiedMedicalPlanner.com

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